Antenatal Care in Poor Countries

Stephen GloydMCH in Developing CountriesJanuary 2012

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Antenatal Care Initiatives

MAKING PREGNANCY SAFER (WHO) Reduce maternal mortality 75% by 2015 SAFE MOTHERHOOD INITIATIVE (WHO-1988)“Four Pillars” Family planning Prenatal care Clean birth Essential obstetric services at referral level

(including availability of transport)

And…Improvement of womens' status

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IMPORTANCE OF ANTENATAL CARE

reduce high perinatal risk reduce high maternal risk (50x) major point of access to health care for

women

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Access to antenatal care

Physical access Time and/or distance to facility Economic costs & barriers Cultural and social factors Quality of care

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Trends in Antenatal care 1990-2000

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Estimates of the proportion of pregnant women who received some antenatal care (1996)

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Number of visits to ANC by region

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Factors affecting the utilization of antenatal care in developing countries: Systematic review of the literatureBibha Simkhada Maureen PorterEdwin R. van Teijlingen Padam Simkhada. Journal of Advanced Nursing, Jan 2008

A systematic review of 28 papers -both quantitative and qualitative

Factors most commonly associated with antenatal care uptake: Maternal education, husband's education, marital status, availability, cost, household income, women's employment, media exposure and having a history of obstetric complications. Also cultural beliefs.

Parity had a statistically significant negative effect on adequate attendance. While women of higher parity tend to use antenatal care less, there is interaction with women's age and religion.

Only one study examined the effect of the quality of antenatal services on utilization. None identified an association between the utilization of such services and satisfaction with them

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Antenatal care and delivery

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Timing of ANC visits (most in 1st trimester except Africa)

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Estimates of the proportion of deliveries attended by skilled personnel (1996)

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Prenatal care vs attended birth and post partum care

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Components of prenatal care:

Health education Screening Diagnosis and treatment Referral

Screening/Dxo Identify women at high risk [?usefulness]o Intervene to prevent development of problemso Dx and Rx pre-existing medical conditionso Dx and Rx complications of pregnancy

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Perinatal Morbidity and Mortality (newborn)

LBW Birth trauma, obstructed labor Infection

amnionitis herpes gonorrhea syphilis streptococcus HIV Tetanus

Abruptio Placenta Congenital malformations "other" (30%)

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Maternal Morbidity and Mortality

(Five main causes) Hemorrhage Sepsis Eclampsia Obstructed Labor Abortion Note: Mortality reduction requires secondary

and tertiary care

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Other Causes of Maternal Morbidity and Mortality

Hypertension Diabetes Heart Disease Hepatitis Anemia Malaria Tuberculosis STDOverall Morbidity: 3-12% of all pregnancies

(up to 37% in India)

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Poor outcomes: 3465 birth registries

in 30 hospitals of Cote d’Ivoire (1997)

Condition Rate per 1000Normal 760

Stillbirth 44

Neonatal death 6

LBW < 2500g < 2000g <1500g

190 52 17

Eclampsia 2

Fetal disproportion 13

Fetal distress 15

Hemorrhage 22

Maternal deaths 2

Others 12

Operative delivery 36

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Prevalence of low birth weight globally

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Sexually transmitted infections (STI) among pregnant women in Mozambique

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Preventability

Overall Infant Deaths - 33% preventable (Nairobi)

Syphilis: 100% preventable 10% stillbirths 20% Infant Mortality 20% Congenital Syphilis

Other causes: % preventable not clear

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Risk Approach

Identification of high risk factors Predictive (Previous fetal loss) Contribution (Grand multipara, young or old) Causation (syphilis, HIV, maternal

malnutrition)

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Risk Approach

Not believed an effective ANC strategy because:

Complications cannot be predicted—all pregnant women are at risk for developing complications

Risk factors are usually not direct cause of complications

Many “low risk” women develop complications Have false sense of security Do not know how to recognize/respond to problems

Most “high risk” women give birth without complications Thus, an inefficient use of scarce resources

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WHO working group on prenatal care 1994

PNC should be individualized Part of overall, functional system Midwife usually most appropriate Include empowerment

WHO Antenatal Care Randomized Trial(Villar et al 2001)

Manual for the Implementation of the New Model

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Current state of Prenatal Care 2008

Too many interventions Poor quality of care for interventions that work Need to focus on a FEW interventions based on

epidemiology

Interventions that are cheap and effective pMTCT (HIV screening and prophylaxis) Malaria IPT (Intermittent Preventive Therapy)

Syphilis screening and Rx Iron therapy Tetanus immunization Family planning Nutritional supplementation

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Other interventions that need more study(though most of these are recommended)

STD identification and treatment Routine anti parasite drugs Waiting houses Diabetes screening (depends on prevalence) Management and treatment of HTN

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HIV in pregnancy

Prevention of HIV transmission (pMTCT) Opt-in vs opt out Single dose Niverapine vs AZT vs HAART Efficiency of treatment

Care for HIV positive mother during pregnancy Special nutritional needs Social needs, stigma

HAART in pregnancy Toxicity (NVP, AZT) Patient flow and adherence

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Prevention of Mother to Child Transmission of HIV (pMTCT)

Short term ARVs reduce transmission by > 50% AZT vs Nevirapine Cost-effectiveness based on prevalence Effectiveness depends on adequate follow up of women

HIV+ to counseling Links between prenatal care and hospital

Implementation Not necessary to wait until everything is in place Important to involve PLWAs Community consultation critical Counselors need training Mothers need support and follow up (including

psychosocial) Works best in conjunction with HAART

Prevention and Control of Malaria during Pregnancy

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Malaria and Pregnancy

30 million African women are pregnant yearly Malaria is more frequent and complicated

during pregnancy In malaria-endemic areas, malaria during

pregnancy may account for: Up to 15% of maternal anemia 5–14% of low birthweight 30% of “preventable” low birthweight

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Effects of Malaria on Pregnant Women

All pregnant women in malaria-endemic areas are at risk

Parasites attack and destroy red blood cells Malaria causes up to 15% of anemia in

pregnancy Can cause severe anemia In Africa, anemia due to malaria causes up to

10,000 maternal deaths per year

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Malaria Prevention and Treatment during Pregnancy

Focused antenatal care (ANC) with health education about malaria

Use of insecticide-treated nets (ITNs) Intermittent preventive treatment (IPT) Case management of women with symptoms

and signs of malaria

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Benefits of Insecticide-Treated Nets

Prevent mosquito bites Protect against malaria, resulting in less:

Anemia Prematurity and low birthweight Risk of maternal and newborn death

Help people sleep better Promote growth and development of fetus

and newborn

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Intermittent Preventive Treatment

Every pregnant woman living in an area of high malaria transmission has malaria parasites in her blood or placenta, whether or not she has symptoms of malaria

Although a pregnant woman with malaria may have no symptoms, malaria can still affect her and her unborn child

Three doses of sulfadoxine-pyrimethamine (SP) should be given to all pregnant women after quickening and at least 1 month apart

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Intermittent Preventive Treatment: Dose and Timing

Each dose is three tablets of sulfadoxine 500 mg + pyrimethamine 25 mg

Ideally, a dose is given at each ANC visit after quickening, but at least 1 month apart

Healthcare provider should dispense dose and directly observe client taking dose

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Intermittent Preventive Treatment: Contraindications to Using SP

First trimester: Be sure quickening has occurred and woman is at least 16 weeks pregnant

Allergy to SP or other sulfa drugs: Ask about sulfa drug allergies before giving SP

Taking co-trimoxazole, or other sulfa-containing drugs: Ask about use of these medicines before giving SP

Not more frequently than monthly: Be sure at least 1 month has passed since the last dose of SP

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Managing Uncomplicated Malaria

Provide first-line anti-malarial drugs Follow country guidelines

Manage fever Analgesics, tepid sponging

Diagnose and treat anemia Provide fluids

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Active Syphilis Infection in Pregnancy

Adverse outcome in 50-70% of infected pregnancies

In sub-Saharan Africa, prenatal syphilis positivity varies between 4-16% (average ~ 9%)

In Zambia & Malawi, 26-42% stillbirths attributed to syphilis

8% of IMR due to syphilis

Screening is effective & inexpensive Basic Screening Test (RPR) costs US$0.25-0.35, takes 15-20

minutes. ICS (Rapid test) ~$0.50, 2 minutes.

Treatment: 3 doses (1 per week) of Benzathine Penicillin at US$1.00 per dose

Estimated screening of women in ANC in Africa - 38%

Obstacles: cost, organization of services

Missed opportunities for screening >1 million

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Focused Antenatal Care

Evidence-based, goal-directed actions Individualized, woman-centered care Early detection and treatment of problems and complications Prevention of complications and disease Quality vs. quantity of visits Care by skilled providers

An approach to ANC that emphasizes:

Birth preparedness & complication readiness

Health promotion

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No Longer Recommended

Numerous, routine visits Burden to women and healthcare system

Routine measurements and examinations: Maternal height and weight Ankle edema Fetal position before 36 weeks

Care based on risk assessment

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Number of antenatal care visits

WHO multi-center study - number of visits reduced without affecting outcome for mother or baby

Recommendations Minimum of 4 visits (see table) – with quality

services Individualized delivery plan depending on risk

profile One PNC visit at referral hospital Health promotion (to individual and community) Emergency transport

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First visit: By 16 weeks or when woman first thinks she is pregnant

Second visit: At 24–28 weeks or at least once in second trimester

Third visit: At 32 weeks

Fourth visit: At 36 weeks

Other visits: If complication occurs, followup or referral is needed, woman wants to see provider, or provider changes frequency based on findings (history, exam, testing) or local policy

Scheduling and Timing of ANC Visits

WHO MNH guidelines

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5 pages of tablesTable 1 lists interventions delivered to the mother during pregnancy, childbirth and in the postpartum period, and to the newborn soon after birth.

Table 2 lists the places where care should be provided through health services, the type of providers required and the recommended interventions and commodities at each level.

Table 3 lists practices, activities and support needed during pregnancy and childbirth by the family, community and workplace.

Table 4 lists key interventions provided to women before conception and between pregnancies.

Table 5 addresses unwanted pregnancies.

http://whqlibdoc.who.int/hq/2007/WHO_MPS_07.05_eng.pdf

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IMPAC Manual

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http://whqlibdoc.who.int/publications/2006/924159084X_eng.pdf

Integrated Management of Pregnancy & Childbirth

GuidelinesWHO2006

IMPAC ManualGuideline detail for Antenatal Care

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1. Assess the pregnant woman

2. Check for pre-eclampsia

3. Check for Anemia

4. Check for syphilis

5. Check for HIV status

6. Respond to observed signs or volunteered problems (no fetal mvmt, ruptured membranes, fever, disuria, vaginal discharge, HIV, smoking, drugs, DV, SOB, TB)

7. Give preventive measures (tetanus, Fe/folate, mebendazole, malaria, ITN)

7. Advice and counsel on nutrition and self care

8. Develop a birth & emergency plan

9. Advise and counsel on family planning

10. Advise on routine and follow up visits

11. Home delivery without a skilled attendant

12. Assess feasibility of ARV for pregnant woman

http://whqlibdoc.who.int/publications/2006/924159084X_eng.pdf

Other useful WHO guidelines

http://whqlibdoc.who.int/hq/2010/WHO_MPS_09.04_eng.pdf

JHPEIGO. Inspired by George Povey Manual http://whqlibdoc.who.int/publications/2007/9241545879_eng.pdf

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Problems with interventions (general):

Utilization is variable

Gestation at first visit (after sixth month)

Variable epidemiology of risk factors (Malaria, eclampsia, Anemia, pelvic size)

Cultural barriers identification of pregnancy, taboosreluctance to use family planning

Limitations of referral and transport

Sensitivity and specificity of risk factors

Thank you!

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Some operational issues – prenatal and birth care

Malaria in pregnancy (done by Paula Brentlinger?)

pMTCT (prevention of mother to child transmission of HIV

Antenatal syphilis screening in Mozambique

Traditional birth attendant training

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Safe childbirth care

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Inadequate health systems

Emergency obstetric care (EOC) requires - Surgical facilities Anesthesia Blood transfusion Manual delivery tools (VE, forceps) Medical treatment (HTN, Sepsis, shock) Family Planning

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Impact of Traditional Birth Attendant training in Rural Mozambique (1)

MOH established a TBA program in

Goals: reduce maternal and infant mortality & improve utilization of primary health care

Over 8 years MOH trained >300 TBAs - supported by quarterly supervision, basic equipment, and annual refresher courses

Surveys showed TBAs improved their knowledge of obstetric emergencies and skills in how to manage them

An evaluation was planned to assess whether the program had met its initial goals (1995)

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Impact of Traditional Birth Attendant training in Rural Mozambique (2)

A retrospective cohort study

Comparison of maternal and newborn outcomes in

40 communities where TBAs had been trained

27 communities where TBAs had not yet been trained.

In each community –respondents interviewed in 30 households closest to the trained TBA (or center of the community with no trained TBA) with pregnancies in the past 3 years

Principal outcomes utilization of TBA or health facility services (delivery and ANC)

outcome of pregnancy for mother and child

utilization of other primary health care services

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Impact of Traditional Birth Attendant training in Rural Mozambique - RESULTS

In TBA trained communities 30% of these pregnant women utilized theTBAs

40% managed to deliver at health facilities

Overall, 70% of women preferred health facility midwives for their next birth (however, most users of trained TBAs preferred TBAs for their next birth)

No difference in mortality rates (perinatal, neonatal, infant)

MOH policy regarding TBA vs health facility support substantially changed after the study

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Basic components of the WHO antenatal care program (1994)

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